Identify Early Warning Signs Of Change In Patient Deterioration

It is not uncommon for hospitalized patients to exhibit early warning signs before deteriorating. The key to optimal outcomes is recognition of these warning signs followed by an appropriate and timely response. Have you ever called the Rapid Response Team (RRT)? What triggered your call? In most U.S. hospitals, a single warning sign, such as a sudden drop in blood pressure, may trigger a call.

Very often, the feeling that “something is just not right” prompts the call. But is there a way to quantify what might be going wrong in order to address the problem earlier?

Enter the Early Warning Scoring System, or EWSS, which can encourage early intervention, timely transfer to a higher level of care and prevention of codes. EWSS originated in the United Kingdom. Over the last few years, U.S. hospitals have begun to utilize the tool here in the states. Implementing EWSS “adds another layer of early detection to the RRT system” (IHI, n.d.) and allows the healthcare team to intervene earlier.

One widely used version is the Modified Early Warning System (MEWS). Healthcare personnel enter vital signs on a chart form that has red-shaded zones to identify findings outside the normal range for six vital signs, namely: Respiratory rate, heart rate, systolic blood pressure, level of consciousness, temperature and hourly urinary output.

When any one of these signs falls into a red zone, the nurse determines a MEWS score for the patient, assigning a number between 0-3 to each of the six vital signs (as shown in the MEWS algorithm chart, below). The nurse then adds the individual scores for a total MEWS score. If the total score is 4 or higher, the nurse is to call the patient’s provider and alert the RRT

MEWS Chart

Hospitals’ protocols and procedures vary in the use of EWSS. Some use the RRT for consultation as well as intervention. Other institutions may not utilize all six of the MEWS parameters, or may modify the tool for specific patient populations such as pediatrics or obstetrics

In some settings, vital signs entered into the EMR “automatically populate a data warehouse that supports a patient risk tool that includes early warning scores for the previous four days as well as patient lab values for the last eight hours, key medications, and so forth. The patient risk tool also shows graphs of patient vitals for the past 48 hours.” The nurse evaluates these reports and decides whether to call the attending physician, alert the RRT, or continue to monitor the patient (IHI, n.d.). Another teaching hospital color codes their levels of EWSS scores (Duncan, et al., 2012):

• Green = normal

• Yellow requires the charge nurse to reassess.

• Orange requires the charge nurse to reassess and notify the resident.

• Red requires that the nurse notify the RRT and resident.

• Orange or red requires resident-to-resident handoff reporting at the bedside.

Use these early warning signs to detect patient deterioration and gain the benefits of early intervention.

RN.com now offers a new course entitled: The Chain of Command Protects Your Patients and You. This 2 contact hour activity reviews some clinical examples of common risk-for-deterioration scenarios and early warning signs that should be acted upon immediately, and suggests ways in which the nurse can successfully navigate the chain of command to prioritize patient safety.

EARLIER WARNING SIGNS OF DETERIOARTION IN CLINICAL CONDITIONS

CLINICAL CONDITIONS	EARLIER WARNINGS	MANAGEMENT
MI(Myocardial Infarction)	· Severe chest pain · Pain in back radiate to L arm · Excessive/ Breathlessness + in some cases	· Complete bed rest,O2 inhalation st&sos maintain BP Chart/TPR
CVA – Cerabrovascular Accident(Stroke)	· Weakness upper / lower extremities or one side of the body irrelevant talk · Slurred Speech · Difficulty to walking	· O2 inhalation st& SOS diet NG tube feeding(if can’t able to eat diet) · Continuous catheterization
Pulmonary Edema	· Breathlessness · Cough C or without expectoration · Tiredness · Palpitation present in severe cases	· Bed rest with propped up position,O2 inhaltion · Diet: Normal
Acute pancreatitis	· Abdomen pain especially right upper · Fever · Nausea and vomiting · Indigestion · Loss of appetite · Abdominal pain radiate to back	· Diet NPO,if severe pain give supportive measures immediately
Cholelithiasis	· Pain upper abdomen · Nausea,Vomiting · Indigestion	· It severe pain give supportive measures
Rhinosporidiosis	· Unilatertal nasal obstruction Rhinoceros post nasal discharge with cough	· Nasal packing (if epitaxis) Give supportive measures
Dengue fever	· High fever with chills · Heaviness of head · Pain in points/Muscle · Extreme tiredness · Loss foappetities	· Diet: More fluid intake observe ½ hearlty(TO PREVENT SHOKE)
Meningitis	· Fever with chills · Headache with pain in back muscles,neck · Stiffness of neck · Nausea and vomiting · Loss of appetite	· Maintain TPR chest give supportive me
Pregnancy induced hypertension	Headache,Vomiting,Blurring of vision	Admit,Maintain TPR BP control
Anteparturm Hemorrhage	Painful bleeding during pregnancy Abruptio placenta	Admit,MonitorTPR,Arrange for Blood transfusion
	Painless bleeding placenta previa	Admit,MonitorTPR,Arrange for Blood transfusion
Hyperemesiagravidorum	Continuous vomiting giddiness	Admit,Monitor TPR, Start IVF